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Coding Facet Joint Injections

By Aimee Wilcox, MA, CST, CCS-P

If you work in pain management, anesthesia or interventional radiology, you are probably keenly aware of the changes that have occurred over the past three years with facet joint injection coding and its effect on your bottom line.

What is a facet joint injection?

A facet joint injection is a diagnostic procedure used to determine if the patient's spine pain is related to arthropathy of the facet joints. During a facet joint block, an anesthetic is injected into the facet joints where the associated spinal nerves travel to see if it will stop or 'block' the pain. Sometimes a steroid is injected with the anesthetic to help with the inflammation.

If the results of the injection prove positive the patient qualifies for a therapeutic procedure called radiofrequency (RF) ablation. (RF) ablation temporarily destroys the affected spinal nerves thereby blocking the pain on a more long-term basis anywhere from six months to a year.

Many patients have back pain which makes this procedure beneficial for many and at the same time ripe for overuse. As such, Medicare has reviewed and researched the effects of this procedure and listed a set of criteria that must be met in order to perform the diagnostic testing and RF ablation. This criteria can be found on the Medicare website.

Payment for services rendered depends on the documentation meeting the criteria put forth by Medicare, so work smartly and efficiently by reviewing the Medicare LCD and make sure your providers are aware of the criteria that must be documented in the patient's record. Let's review the main issues surrounding coding this procedure.

Understanding Spinal Anatomy

Understanding spinal anatomy is the second step to ensuring reimbursement through correct coding. Most coders under or over code facet blocks because of the odd number of nerves to vertebra that occur in the cervical spine. Let's take a moment and review the spinal anatomy you'll need to know for correct code selection.

There are four regions of the spine: cervical, thoracic, lumbar and sacral/coccyx.
Each region contains numbered vertebrae and numbered nerves

Vertebra:

Cervical 1-7

Thoracic 1-12

Lumbar 1-5

Sacral 1-5/Coccyx 1-4

Nerves:

Cervical 1-8

Thoracic 1-12

Lumbar 1-5

Sacral 1-5/Coccyx 1

The facet joint is a synovial joint located between the superior articular process of one vertebra and the inferior articular process of the vertebra directly above it.

Facet joints are also referred to as zygapophyseal joints and Z-joints, so watch for these alternative terms in the documentation.

Each facet joint is innervated by two spinal nerves.

As there is one more cervical nerve than there are vertebrae, the level listed will no longer match up perfectly starting with the C7-T1 facet joint. Because of the 'extra' C8 nerve, all the nerves of the thoracic, lumbar and sacral/coccygeal regions are innervated by the nerve above and below the facet joint. Example: L4-5 is innervated by "L3, L4" not "L4, L5"

As a coder, make sure you thoroughly understand the nerves assigned to each facet joint well. Anatomy is a must for this procedure.

CPT Code Selection

There are up to three CPT codes used to report facet joint injections based on spinal region. The codes allow for three levels maximum per session. Anything over three are considered free of charge, as they will not be reimbursed.

The T12-L1 facet joint is considered part of the lumbar/sacral region when coding facet joint injections.

Industry Standard Documentation Aids Code Selection

The next major issue with coding facet joint injections correctly is understanding the documentation. There is an industry standard way to document facet joint injections. When providers do not follow industry standard documentation practices over-coding or under-coding usually occurs.

Let's review the documentation issues you may encounter and what they mean:

Standard documentation lists the facet joint to be blocked with hyphens.

---Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code.
For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding.

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